is like being grateful the mugger didn’t just kill you.
The appalling incompetence of the rollout of ACA might well stand as a symbol of the entire package. In America, the term ‘healthcare’ is an oxymoron, having very little to do with taking care of the health of the citizenry and much to do with making the insurance and pharmaceutical companies richer.
That’s the ONLY reason their lobbyists allowed the law to pass and they didn’t allow it until they were satisfied with the fine print. And, of course, until their political toadies’ speechwriters had come up with acceptable doublespeak.
It doesn’t have to be that way.
The biggest downside of the ACA is the reliance on the private insurance industry. [] There is yet another provision in the Affordable Care Act that can open the door for states to institute their own single-payer healthcare system.
Vermont decided to [] set[] up their very own single payer system.
The program will be fully operational by 2017, and will be funded through Medicare, Medicaid, federal money for the ACA given to Vermont, and a slight increase in taxes. In exchange, there will be no more premiums, deductibles, copay’s, hospital bills or anything else aimed at making insurance companies a profit. Further, all hospitals and healthcare providers will now be nonprofit.
Everyone will be able to go to any doctor or hospital in the state free of charge. No plans to figure out, no insurance forms to sweat over, no gotchas.
Another advantage of a single-payer system is the ability of the state [Vermont] to negotiate more aggressively with pharmaceutical companies and medical equipment suppliers There is no reason drugs and equipment should be so expensive here and cheaper abroad.
I haven’t seen the fine print on Vermont’s plan – don’t khow if it’s even gotten that far yet – so I can’t comment on the non-profit status of hospitals and healthcare providers, However, a good argument can be made that the first priority of a corporation should be to operate to the benefit of the public and only secondarily to the benefit of the corporate owners. That was, in fact, the original justification for corporations.
(Utah Phillips once spoke of the difference between making a living and making a killing.) 🙂
For millions of people, healthcare in this county sucks, particularly compared to other First World countries (which group is unlikely to include us a few years from now). I happen to have excellent medical coverage – unless I outlive my wife or the vultures manage to privatize USPS and loot the pension and benefit funds, in which case I’d be screwed. Vermont has been on my shortlist of possible places to relocate in the next year or two and a big part of that is their more humane sociopolitical outlook and culture. This just confirms that judgment.
Here is a partial list of exclusions in an ACA compliant policy (Platinum level) from Humana:
Limitations and exclusions (things that are not covered)
This is an outline of the limitations and exclusions for the Humana individual health plan listed above. It is designed for convenient reference. Consult the policy for a
complete list of limitations and exclusions. The policy is guaranteed renewable as long as premiums are paid. Other termination provisions apply as listed in the policy.
Unless specifically stated otherwise, no benefits
will be provided for, or on account of, the following
items:
1. Services which require a primary care physician
referral if a referral was not obtained;
2. Services provided by a non-network provider,
except when:
a. Authorized by us;
b. A referral is obtained from a primary care
physician; or
c. The following services are medically
necessary to render emergency care;
i. Professional ambulance service;
ii. Services in a hospital emergency room; or
iii. Services in an urgent care center;
3. Services provided by a non-network provider
except as expressly provided in the policy;
4. Services for care and treatment of non-covered
procedures;
5. Services incurred before the effective date or
after the termination date;
6. Services not medically necessary for diagnosis
and treatment of a bodily injury or sickness,
except for the specified routine preventive
services;
7. Charges for prophylactic services including, but
not limited to, prophylactic mastectomy or any
other services performed to prevent a disease
process from becoming evident in the organ
tissue at a later date;
8. Services which are experimental,
investigational or for research purposes, or
related to such, whether incurred prior to, in
connection with, or subsequent to the service
which is experimental, investigational or
for research purposes as determined by us.
The fact that a service is the only available
treatment for a condition may not make
it eligible for coverage if we deem it to be
experimental, investigational or for research
purposes;
9. Complications directly related to a service
that is not a covered expense under the
policy because it was determined by us to be
experimental, investigational or for research
purposes or not medically necessary. Directly
related means that the service occurred
as a direct result of the experimental,
investigational or for research purposes or
not medically necessary service and would
not have taken place in the absence of the ,
experimental, investigational or for research
purposes or not medically necessary service;
10. Charges in excess of the maximum allowable
fee for the service;
11. Services exceeding the amount of benefits
available for a particular service;
12. Services for any condition excluded by rider or
amendment under the policy;
13. Services provided when the policy is past
premium due date, and payment is not
received;
14. Services for treatment of complications of noncovered
procedures or services;
15. Services relating to a sickness or bodily injury
incurred as a result of the covered person:
a. Being intoxicated, if the use of alcohol
substantially contributes to or causes the
loss, or if the covered person is intoxicated
over the legal limit. A covered person is
conclusively determined to be intoxicated
over the legal limit if a chemical test
administered in the jurisdiction where the
loss occurred is at or above the legal limit
set by that jurisdiction; or
b. Being under the influence of illegal narcotics
or controlled substance unless administered
or prescribed by a healthcare practitioner;
16. Services relating to a sickness or bodily injury
as a result of:
a. Intentionally self-inflicted bodily harm or
attempted suicide whether sane or insane;
b. War or an act of war, whether declared or
not;
c. Taking part in a riot as a voluntary
participant;
d. Engaging in an illegal occupation as a
voluntary participant; or
e. Any act of armed conflict, or any conflict
involving armed forces or any authority;
17. Services:
a. For charges which are not authorized,
furnished or prescribed by a healthcare
practitioner or healthcare treatment facility;
b. For which no charge is made, or for
which the covered person would not be
required to pay if he/she did not have this
insurance, unless charges are received
from and reimbursable to the United States
government, or any of its agencies as
required by law;
c. Furnished by or payable under any plan or
law through a government or any political
subdivision, unless prohibited by law;
d. Furnished while a covered person is
confined in a hospital or institution
owned or operated by the United States
government or any of its agencies for any
service-connected sickness or bodily injury;
e. For charges received from a healthcare
practitioner over the rate we would pay for
the least costly provider;
f. Which are not rendered or not
substantiated in the medical records;
g. Provided by a family member or person who
resides with the covered person;
h. Rendered by a standby healthcare
practitioner, surgical assistant, assistant
surgeon, physician assistant, nurse or
certified operating room technician unless
medically necessary; or
i. Performed in association with a non-covered
service.
18. Any charges, including healthcare practitioner
charges, which are incurred if a covered
person is admitted to a hospital on a Friday or
Saturday unless:
a. The hospital admission is due to emergency
care; and
b. Treatment or surgery is performed on that
same day;
19. Hospital inpatient services when the covered
person is in observation status;
20. Cosmetic services, or any complication
therefrom;
21. Custodial care and maintenance care;
22. Ambulance services for routine transportation
to, from or between medical facilities and/or a
healthcare practitioner’s office;
23. Elective medical or surgical procedures except
elective tubal ligation and vasectomy;
24. Elective medical or surgical abortion unless:
a. The pregnancy would endanger the life of
the mother; or
b. The pregnancy is a result of rape or incest;
25. Reversal of sterilization;
26. Infertility services except as expressly provided
in the “Preventive services” provision in the
“Your Policy Benefits” section;
27. Sexual dysfunction;
28. Sex change services, regardless of any
diagnosis of gender role or psychosexual
orientation problems;
29. Vision examinations or testing for the
purposes of prescribing corrective lenses;
radial keratotomy; refractive keratoplasty;
or any other surgery or procedure to correct
myopia, hyperopia or stigmatic error; orthoptic
treatment (eye exercises); or the purchase or
fitting of eyeglasses or contact lenses, unless
specified in the policy;
30. Dental services, appliances or supplies for
treatment of the teeth, gums, jaws or alveolar
processes including, but not limited to,
excision of partially or completely unerupted
impacted teeth, any oral or periodontal surgery
and preoperative and post operative care,
implants and related procedures, orthodontic
procedures, and any dental services related to
a bodily injury or sickness except as expressly
provided in the policy;
31. Pre-surgical/procedural testing duplicated
during a hospital confinement;
32. Any treatment for obesity, regardless of any
potential benefits for co-morbid conditions,
including but not limited to:
Network agreements
Network providers agree to accept an agreed-upon amount as payment in full. Your policy explains your share of the cost of services rendered by network
providers. It may include a deductible, a set amount (copayment), and a percent of the cost (coinsurance).
When you go to a network provider:
• The amount you pay is based on the agreed-upon amount.
• The provider can’t “balance bill” you for charges greater than that amount.
• There are primary care physician (PCP) selection requirements and specialist
referral requirements.
• Primary care physician (PCP) referral is not required for network obstetrician
and gynecologist services.
When you go to an out-of-network provider::
• There is no coverage for out-of-network providers, except for emergency
care as defined in your policy.
Page 8 of 12
a. Surgical procedures for morbid obesity;
b. Services or procedures for the purpose of
treating a sickness or bodily injury caused
by, complicated by, or exacerbated by the
obesity; or
c. Complications related to any services
rendered for weight reduction;
33. Surgical procedures for the removal of excess
skin and/or fat in conjunction with or resulting
from weight loss or a weight loss surgery;
34. Treatment of nicotine habit or addiction,
including but not limited to, nicotine patches,
hypnosis, smoking cessation classes, tapes
or electronic media; except as eligible for
coverage under preventive services;
35. Educational or vocational training or therapy,
services, and schools including but not limited
to videos and books;
36. Foot care services including but not limited to:
a. Shock wave therapy of the feet;
b. Treatment of weak, strained, flat, unstable
or unbalanced feet;
c. Hygienic care, and the treatment of
superficial lesions of the feet, such as corns,
calluses or hyperkeratosis;
d. Tarsalgia, metatarsalgia or bunion
treatment, except surgery which involves
exposure of bones, tendons or ligaments;
e. Cutting of toenails, except removal of nail
matrix; and
f. Arch supports, heel wedges, lifts, shoe
inserts, the fitting or provision of foot
orthotics or orthopedic shoes, unless
medically necessary because of diabetes or
hammertoe;
37. Hair prosthesis, hair transplants or implants;
38. Hearing care that is routine, including but
not limited to exams and tests, any artificial
hearing device, cochlear implant, auditory
prostheses or other electrical, digital,
mechanical or surgical means of enhancing,
creating or restoring auditory comprehension;
39. Services rendered in a premenstrual syndrome
clinic or holistic medicine clinic;
40. Transplant services except as expressly
provided in the policy;
41. Charges for growth hormones (drugs,
medications or hormones to stimulate growth);
42. Over the counter medical items or supplies
that can be provided or prescribed by a
healthcare practitioner but are also available
without a written order or prescription, except
for preventive services;
43. Immunizations including those required for
foreign travel for covered persons of any age
except as expressly provided in the policy;
44. Treatment for any jaw joint problem, including
but not limited to, temporomandibular
joint disorder, craniomaxillary disorder,
craniomandibular disorder, head and neck
neuromuscular disorder or other conditions of
the joint linking the jaw bone and skull;
45. Genetic testing, counseling or services;
46. Charges for which there is automobile or any
other insurance providing medical payments;
47. Sickness or bodily injury for which medical
payments/personal injury protection (PIP)
coverage exists under any automobile,
homeowner, marine, aviation, premise or any
other similar coverage whether such coverage
is in effect on a primary, secondary, or excess
basis. This exclusion applies up to the available
limit under the other coverage regardless
of whether a claim is filed with the medical
payments/PIP carrier. Whether medical
payment or expense coverage is payable under
another coverage is to be determined as if the
coverage under the policy did not exist;
48. Covered expense to the extent of any amount
received from others for the bodily injuries
or losses which necessitated such benefits.
Amounts received from others specifically
includes, without limitation, liability insurance,
Workers’ Compensation, uninsured motorists,
underinsured motorists, “no-fault” and
automobile medical payments;
49. Expense for employment, school, sports or
camp physical examinations or for the purpose
of obtaining insurance, premarital tests/
examinations;
50. Services received in an emergency room unless
required because of emergency care;
51. Any expense incurred for services received
outside of the United States except as required
by law for emergency care services;
52. Services received during an inpatient
stay when the stay is primarily related to
behavioral, social maladjustment, lack of
discipline or other antisocial actions which are
not specifically the result of mental health;
53. Services and supplies which are:
a. Rendered in connection with mental
illnesses not classified in the International
Classification of Diseases of the U.S.
Department of Health and Human Services;
b. Extended beyond the period necessary
for evaluation and diagnosis of learning
and behavioral disabilities or for mental
retardation; and
c. Specifically excluded is marriage counseling;
54. No benefits will be provided for:
a. Immunotherapy for recurrent abortion;
b. Chemonucleolysis;
c. Biliary lithotripsy;
d. Home uterine activity monitoring;
e. Sleep therapy;
f. Light treatment for Seasonal Affective
Disorder (S.A.D.);
g. Immunotherapy for food allergy;
h. Prolotherapy;
i. Cranial banding, unless otherwise
determined by us;
j. Hyperhydrosis surgery; and
k. Sensory integration therapy;
55. Services or supplies provided in connection
with a sickness or bodily injury arising out of,
or sustained in the course of, any occupation,
employment or activity for compensation,
profit or gain, whether or not benefits are
available under Workers’ Compensation except
as expressly provided in the policy;
56. Court-ordered mental health services;
57. Charges for alternative medicine, including
medical diagnosis, treatment and therapy.
Alternative medicine services includes, but is
not limited to:
a. Acupressure;
b. Acupuncture;
c. Aromatherapy;
d. Ayurveda;
e. Biofeedback;
f. Faith healing;
g. Guided mental imagery;
h. Herbal medicine;
i. Holistic medicine;
j. Homeopathy;
k. Hypnosis macrobiotic;
l. Massage therapy;
m. Naturopathy;
n. Ozone therapy;
o. Reflexotherapy;
p. Relaxation response;
q. Rolfing;
r. Shiatsue; and
s. Yoga;
58. Services in a convenient care clinic;
59. Private duty nursing;
60. Living expenses; travel; transportation, except
as expressly provided in the “Ambulance
services” provision or “Transplants” provision in
the “Your Policy Benefits” section of the policy;
and
61. Charges for services that are primarily
and customarily used for a non-medical
purpose or used for environmental control or
enhancement (whether or not prescribed by
a healthcare practitioner) including but not
limited to:
a. Common household items such as air
conditioners, air purifiers, water purifiers,
vacuum cleaners, waterbeds, hypoallergenic
mattresses or pillows, or exercise
equipment;
b. Scooters or motorized transportation
equipment, escalators, elevators, ramps,
modifications or additions to living/working
quarters or transportation vehicles;
c. Personal hygiene equipment including
bath/shower chairs, transfer equipment or
supplies or bed side commodes;
d. Personal comfort items including cervical
pillows, gravity lumbar reduction chairs,
swimming pools, whirlpools or spas or
saunas;
e. Medical equipment including blood pressure
monitoring devices, breast pumps, PUVA
lights and stethoscopes;
f. Charges for any membership fees or
program fees paid by a covered person,
including but not limited to, health
clubs, health spas, aerobic and strength
conditioning, work-hardening programs
and weight loss or similar programs and
any related material or products related to
these programs;
g. Communication system, telephone,
television or computer systems and related
equipment or similar items or equipment;
and
h. Communication devices except after
surgical removal of the larynx or a diagnosis
of permanent lack of function of the larynx.
Page 9 of 12
Prescription Drug Exclusions
1. Growth hormones (medications, drugs or
hormones to stimulate growth) for idiopathic
short stature;
2. Growth hormones, (medications, drugs
or hormones to stimulate growth), unless
there is a laboratory confirmed diagnosis of
growth hormone deficiency, or as otherwise
determined by us;
3. Contraceptives, including oral and transdermal,
whether medication or device, when
prescribed for purpose(s) other than to prevent
pregnancy;
4. Drugs which are not included on the drug list;
5. Dietary supplements except enteral formulas
and nutritional supplements for the treatment
of phenylketonuria (PKU) or certain other
inherited metabolic disease;
6. Nutritional products;
7. Fluoride supplements;
8. Minerals;
9. Herbs and vitamins;
10. Legend drugs which are not deemed medically
necessary by us;
11. Any drug prescribed for a sickness or bodily
injury not covered under the policy;
12. Any drug prescribed for intended use other
than for:
a. Indications approved by the FDA;or
b. Off-label indications recognized through
peer-reviewed medical literature;
13. Any drug, medicine or medication that is
either:
a. Labeled “Caution-limited by Federal law to
investigational use”; or
b. Experimental, investigational or for research
purposes, even though a charge is made to
the covered person;
14. Allergen extracts;
15. The administration of covered medication(s);
16. Therapeutic devices or appliances, including
but not limited to:
a. Hypodermic needles and syringes except
needles and syringes for use with insulin,
and self-administered injectable drugs
whose coverage is approved by us;
b. Support garments;
c. Test reagents;
d. Mechanical pumps for delivery of
medication; and
e. Other non-medical substances;
17. Anabolic steroids;
18. Anorectic or any drug used for the purpose of
weight control;
19. Abortifacients (drugs used to induce abortions);
20. Any drug used for cosmetic purposes, including
but not limited to:
a. Tretinoin, e.g. Retin A, except if the
covered person is under the age of 45 or is
diagnosed as having adult acne;
b. Dermatologicals or hair growth stimulants;
or
c. Pigmenting or de-pigmenting agents, e.g.
Solaquin;
21. Contrary to any other provisions of the policy,
we may decline coverage or, if applicable,
exclude from the drug list any and all
prescriptions, including new indications for
an existing prescription, until the conclusion
of a review period not to exceed six months
following FDA approval for the use and release
of the prescription, including new indications
for an existing prescription into the market;
22. Any drug or medicine that is:
a. Lawfully obtainable without a prescription
(over the counter drugs), except insulin;
or drugs, medicines or medications on
the Women’s Healthcare Drug List with a
prescription from a healthcare practitioner;
b. Available in prescription strength without a
prescription;
23. Compounded drugs in any dosage form except
when prescribed for pediatric use for children
up to 19 years of age;
24. Progesterone crystals or powder in any
compounded dosage form, unless otherwise
determined by us;
25. Infertility services including medications;
26. Any drug prescribed for impotence and/or
sexual dysfunction, e.g. Viagra;
27. Any drug, medicine or medication that is
consumed or injected at the place where
the prescription is given or dispensed by the
healthcare practitioner;
28. Drug delivery implants;
29. Treatment for Onychomycosis (nail fungus);
30. Prescriptions that are to be taken by or
administered to the covered person, in whole
or in part, while he/she is a patient in a facility
where drugs are ordinarily provided by the
facility on an inpatient basis. Inpatient facilities
include, but are not limited to:
a. Hospital;
b. Skilled nursing facility; or
c. Hospice facility;
31. Injectable drugs, including but not limited to:
a. Immunizing agents unless otherwise
determined by us;
b. Biological sera;
c. Blood;
d. Blood plasma;
e. Self-administered injectable drugs or
specialty drugs for which coverage is not
approved by us; or
f. Flu and pneumonia vaccines;
32. Prescription refills:
a. In excess of the number specified by the
healthcare practitioner; or
b. Dispensed more than one year from the
date of the original order;
33. Any portion of a prescription or refill that
exceeds a 90-day supply when received from
either a mail-order pharmacy or from a retail
pharmacy that participates in our program
which allows a covered person to receive a
90-day supply of a prescription or refill;
34. Any portion of a prescription or refill that
exceeds a 30-day supply when received from
a retail pharmacy that does not participate in
our program which allows a covered person
to receive a 90-day supply of a prescription or
refill;
35. Any portion of a specialty drug or selfadministered
injectable drug that exceeds a
30-day supply, unless otherwise determined
by us;
36. Any drug for which preauthorization and
notification or step therapy is required, and not
obtained;
37. Any drug for which a charge is customarily not
made;
38. Any portion of a prescription or refill that:
a. Exceeds our drug specific dispensing limit
(i.e. IMITREX);
b. Is dispensed to a covered person whose
age is outside the drug specific age limits
defined by us;
c. Is refilled early, as defined by us; or
d. Exceeds the duration-specific dispensing
limit;
39. Any drug, medicine or medication received by
the covered person:
a. Before becoming covered under the benefit;
or
b. After the date the covered person’s
coverage under the policy has ended;
40. Any costs related to the mailing, sending or
delivery of prescription drugs;
41. Any intentional misuse of the benefit, including
prescriptions purchased for consumption by
someone other than the covered person;
42. Any prescription or refill for drugs, medicines
or medications that are lost, stolen, spilled,
spoiled or damaged;
43. Any drug, medication, or supply to eliminate
or reduce a dependency on or addiction to
tobacco and tobacco products except as
eligible for coverage under preventive services;
44. Any drug or biological that has received
designation as an orphan drug unless
approved by us;
45. Any amount the covered person paid for a
prescription that has been filled, regardless of
whether the prescription is revoked or changed
due to adverse reaction or change in dosage or
prescription; and
46. Prescription dru
If this is Humana’s Platinum plan, the Bronze plan must be “Heart attack? Take two aspirin and call me in the morning”.
It’s as though they ban 90% of the situations that would require payouts. And that’s without looking at the details of how much they pay for particular services or which circumstances are excluded by any riders or amendments – or judging the premiums.
How can anybody look at that policy and not realize it’s a scam?
I agree that even crappy coverage is better than none, but that fact itself speaks volumes about the way the country is run.
The real benefit your friend will reap by being insured is that providers will no longer collect ‘full fare’.
When I review my medical insurance payments, I see (just as an example), a billed amount of $250; Medicare ‘allowing’ $68 and paying $42; my secondary paying $26 and I pay nothing. Uninsured, I’d be on the hook for $250, not the $68 the provider ended up settling for.
This tells me twe things:
1) Providers have learned the game – to collect $68, bill $250.
2) Providers stick it to the uninsured because they have nobody on their side.
I don’t know if you read the good argument can be made link, but if corporations will not operate to the the benefit of the public, why are they entitled to the special financial and legal privileges corporations enjoy? Healthcare should be a not-for-profit universal entitlement, just like decent housing, employment, good schools and all the other civilized (i.e. socialist) goodies.
steeleweed – I agree with much of what you have posted, except your opening comment. For millions of people, getting healthcare via ACA is the first medical insurance they have ever been able to afford. I have a friend, a diagnosed paranoid schizophrenic who works for a shitty, small manufacturing firm who doesn’t offer health insurance to their employees and he is now able to get coverage because of ACA. At 53 and unmarried, he has had a miserable existence, forgoing health care until he has problems so severe he has to go to an emergency room, like for an abcessed tooth. He was weeping on the phone the other night, telling me he is going to be able to get a “bronze” plan for about $285 per month. I agree we should have universal, single payer health insurance and I hope the CEOs of large insurance and pharmaceutical companies burn in Hell for the way they have raped American consumers – but please don’t belittle the good that the ACA has done for people like my friend and compare it to a “mugging”!